Intake Form: Adoption

There's no denying that the adoption process involves a lot of paperwork. If you are seeking the aid, advice, and counsel of an adoption attorney, he or she will guide you through the mountains of paper that lead to your child. In order to do so, you will need to provide your attorney with a vast amount of information. You can expedite the process by completing the following questionnaire before your first meeting with your lawyer.

   
ADOPTIVE MOTHER ADOPTIVE FATHER
Name________________________________ ______________________________
Date of Birth___________________________ ______________________________
Social Security Number__________________ ____________________

Address, Including County


 

 

 

 

 

 
Length of Time at that Address    _______ years _______ years
Previous Address(es) (for last 10 years)

 

 

 

 

 

 
Home Telephone Number ____________________ ____________________
Work Telephone Number ____________________ ____________________
Facsimile Number ____________________ ____________________
E-mail Address ____________________ ____________________
Former Name(s) ____________________ ____________________
____________________ ____________________
Employers ____________________ ____________________
Position ____________________ ____________________
Employer's Address
______________________________ ______________________________
______________________________ ______________________________
______________________________ ______________________________
Length of Time with Employer _______ years _______ years
Previous Employer(s) (for last 10 years)
______________________________ ______________________________
______________________________ ______________________________
______________________________ ______________________________
______________________________ ______________________________
Gross Monthly Income $_________________ $_________________
Other Income
Source/Amount ________________________ _________________________
Source/Amount ________________________ _________________________
Source/Amount ________________________ _________________________
Date of Marriage _________________________________
Place of Marriage ________________________________
Previous Marriage(s)   Yes ____    No ____ Yes ____   No ____
Ended by: Ended by:
Death ____ Divorce ____ Date ______ Death ____ Divorce ____ Date _____
Death ____ Divorce ____ Date _____ Death ____ Divorce ____ Date _____
Children of Current Marriage
Name                                         Date of Birth Adopted?        Living in home?         Race/Nationality
_______________________   _________ Yes/No                 Yes/No                     __________
_______________________   _________ Yes/No                 Yes/No                     __________
_______________________   _________ Yes/No                 Yes/No                     __________
_______________________   _________ Yes/No                 Yes/No                     __________
_______________________   _________ Yes/No                 Yes/No                     __________
Children from Other Marriages or Relationships
Name                                         Date of Birth Adopted?        Living in home?         Race/Nationality
_______________________   _________ Yes/No                 Yes/No                     __________
_______________________   _________ Yes/No                 Yes/No                     __________
_______________________   _________ Yes/No                 Yes/No                     __________
_______________________   _________ Yes/No                 Yes/No                     __________

I/we am/are interested in (check all that apply):

Domestic Adoption _____    Intercountry Adoption _____    Open Adoption _____

Closed Adoption _____    Infant Adoption _____ (under 12 months)

Older Child _____ (state desired age range _____-_____)    Sibling Groups _____

Do you have a gender preference? Yes, I/we prefer a ___________.    No _____

State desired race or ethnicity of child(ren), if any.    _____________________

If you are contemplating intercountry adoption, are there particular countries you are interested in?  _______________________

I/we have the following amount available to fund the adoption (may affect options that can be pursued):

Up to $1,000 _____    $1,000 to $5,000 _____    $5,000 to $10,000 _____

$10,000 to $20,000 _____    $20,000 to $30,000 _____    Over $30,000 _____

Do you have a completed home study?    Yes _____ No _____

Has an adoption ever been denied to you?    Yes _____ No _____

Have you ever been arrested?    Adoptive mother: _______     Adoptive father: _______

If yes, explain:





Are you in good health?    Adoptive mother: ________ Adoptive father: _______

Explain all current and chronic illnesses, past and future surgeries, medications you are currently taking, and other relevant health information:




Do you have a history of alcohol or drug abuse?    Adoptive mother: ________    Adoptive father: ________

List three references who have known you for at least five years. Include a family member, a co-worker, and a social friend or neighbor.

Name                        Address Relationship            How long known?
______________    ____________________ _______________    ____________
______________    ____________________ _______________    ____________
______________    ____________________ _______________    ____________

Other Important Information





Questions to Ask My Attorney





Next Steps

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